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The Clinical Excellence Commission The eChartbook


CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTION CEC eChartbook
Central Line Associated Bloodstream Infection (CLABSI) in Intensive Care Units
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Why is this important?


A central line (also known as a central venous catheter) is an intravenous line that is used to give patients fluids and/or medications. Central lines access a major vein close to the heart and can remain in place for up to several months. Despite patients in Intensive Care Units (ICUs) being at high risk of developing healthcare associated infections (HAIs), central lines are commonly used in this setting [1]. This prevalent use means that central line associated bloodstream infections (CLABSIs) are among the most common HAIs found in ICU settings. There are approximately 3,500 cases of bloodstream infections associated with intravascular catheters in ICU in Australia each year [ 2 ]. Literature suggests that CLABSIs account for 40-60 per cent of all HAIs occurring in ICU patients and the occurrence of CLABSI is a key indicator of the safety of ICU's clinical practice processes [2]. CLABSI also results in prolonged hospital stays, significant morbidity and an increase in mortality [3]-[5].


In 2007-2008, the NSW Central Line-Associated Bacteraemia (CLAB) ICU project was conducted by the Clinical Excellence Commission (CEC) and the Intensive Care Co-ordination and Monitoring Unit (ICCMU), with the support of NSW Health. The project enlisted the participation of 37 NSW ICUs. During the 18-month project, the CLABSI rate reduced from of 3.8/1000 line days (months 1-12) to 1.6/1000 line days (months 13-18) [6]. Based on this project and other successful projects undertaken locally and overseas [3],[7], the Australian and New Zealand Intensive Care Society was later granted funding by the Australian Commission on Safety and Quality in Health Careto lead a national project to prevent CLABSI in Australian ICUs. The aims of the national project were to:

  • reduce Australian ICU CLABSI to <1/1000 line days, and
  • facilitate accurate and consistent CLABSI measurement, with timely reporting to clinicians and benchmarking opportunities.

Since January 2008, NSW Health has also included CLABSI in its statewide surveillance of HAIs occurring across the state and has collected monthly data on this clinical indicator [8].



References
[1] Australian and New Zealand Intensive Care Society (ANZICS) & the Australian Commission on Safety and Quality in Health Care (ACSQHC). Central Line Associated Bloodstream Infection (CLABSI) Prevention Project Report 2012. Accessed November 2013: http://www.anzics.com.au/safety-quality/clab.
[2] Harrington G, Richards M, Solano T, et al. Adult intensive care unit acquired infection. In: Cruickshank M, Ferguson J, editor(s). Reducing harm to patients from health care associated infections: the role of surveillance. Sydney: Australian Commission on Safety and Quality in Health Care; 2008.
[3] Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006. 355 (26):2725-32.
[4] Halton KA, Cook D, Paterson DL, et al . Cost-effectiveness of a central venous catheter care bundle. PLoS One. 2010; 5(9): e12815
[5] Stevens V, Geiger R, Concannon C, et al. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect. 2013; Epub
[6] McLaws ML, Burrell AR. Zero risk for central-line associated bloodstream infections: are we there yet? Crit Care Med. 2012; 40 (2): 388-93.
[7] Collignon P, Dreimanis DE, Beckingham WD, et al. Intravascular catheter bloodstream infections: an effective and sustained hospital-wide prevention program over 8 years. Med J Aust. 2007; 187(10): 551-554.
[8] NSW Health, Healthcare Associated Infection: Clinical Indicator Manual Version 2.0. Accessed 11 November 2013 [Online]: http://www0.health.nsw.gov.au/resources/quality/hai/pdf/clin_ind_man_nov_2008.pdf

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Findings


The  rate of CLABSI in ICUs across NSW was calculated for the period between January 2009 and Jun 2016. Over the period, the annual rate of CLABSI sharply dropped from 1.43 in 2009 to 0.21 per 1,000 line days in 2015. It is interesting to see whether the annual rate for 2016 will follow the decreasing pattern. Six months into 2016, the CLABSI rate was 0.36 per 1,000 line days. This is higher than 0.26 of the same period last year (Jan-Jun 2015).

Since 2011, the rates have remained lower than the national agreed target (1.0) (Chart CL01). The rates should however be interpreted with caution as they were based on small number of infections. For example, of the 70,628 central line days reported by ICUs across NSW in 2015, 15 were central line associated bloodstream infections (CLABSI).

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Implications


The reduction in CLABSI rate during this period is likely to also manifest in a reduction in length of hospitalisation and infection-related morbidity and mortality. Continued effort is required for further incidence reduction.

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What we don't know


Although the hospital-associated risk factors for CLABSI are known [9-10] the underlying patient factors associated are also important in determining the likelihood of infection and associated outcomes. Further investigation is required to determine the contribution of these factors.



References
[9] Wylie MC, Graham DA, Potter-Bynoe G, et al. Risk factors for central line-associated bloodstream infection in pediatric intensive care units. Infect Control Hosp Epidemiol. 2010;31(10):1049-56.
[10] Costello JM, Graham DA, Morrow DF, et al. Risk factors for central line-associated bloodstream infection in a pediatric cardiac intensive care unit. Pediatr Crit Care Med. 2009;10(4):453-9.

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Chart CL01 - CLABSI in ICU adult patients
 

Monthly CLABSI rates per 1,000 line days in ICU adult patients (public hospitals), NSW, Jan 2011-Jun 2016



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Source: Clinical Excellence Commission, NSW Ministry of Health.

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End Matter


Contributors
Drafted by: CEC eChartbook team and CEC Clinical Governance Directorate
Data analysis by: CEC eChartbook team

Reviewed by: CEC Clinical Governance Directorate
Edited by: CEC eChartbook team


Suggested citation
Clinical Excellence Commission [access year]. eChartbook Portal: Safety and Quality of Healthcare in New South Wales. Sydney: Clinical Excellence Commission. Available at: http://www.cec.health.nsw.gov.au/echartbook/cec-indicators-intro-echartbook/clabsi Accessed (insert date of access).


© Clinical Excellence Commission 2016
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Clinical Excellence Commission (CEC). Requests and enquiries concerning reproduction and rights should be directed to the Director, Corporate Services,Locked Bag 8, Haymarket, NSW 1240.


Evidence-base for this initiative
Burrell et al. Aseptic insertion of central venous lines to reduce bacteraemia Med J Aust 2011; 194 (11): 583-587 - www.mja.com.au/journal/2011/194/11/aseptic-insertion-central-venous-lines-reduce-bacteraemia


Reported elsewhere
Healthcare Associated Infection, NSW MOH - www.health.nsw.gov.au/professionals/hai/

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Definitions


Chart: CL01

Admin Status: Current, Jun 2016

Indicator Name: CLABSI in ICU adult patients

Description: Monthly CLABSI rate per 1,000 line days in ICU adult patients (public hospitals), NSW, Jan 2011 - Jun 2016

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: All CLABSIs in adult patients in ICUs

Data Exclusions: None

Numerator: Total number of CLABSIs in adult patients in ICUs

Denominator: Total number of central line days in adult patients in ICUs

Standardisation: None (crude infection rate per 1,000 central line days calculated)

Data Source: NSW Health Healthcare Associated Infections Data Collection, NSW Ministry of Health

Comments: Not applicable

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